The Real Cost of Botox for Migraineurs

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As I was injecting one of my chronic migraine patients with onabotulinumtoxin A (BOTOX) in the occipitalis, I joked with her that if her migraines didn’t improve, at least she would have fewer wrinkles in the back of her scalp. She huffed and said “These injections have saved my life! I don’t know how I would be functioning without them.”

I have seen sufficient benefit from BOTOX injections to recommend this treatment option for chronic migraineurs. I have learned the injection procedure so that my patients have this available as a valid option for their migraines.

Migraine prevention is a desirable goal, especially for patients with frequent migraines. But what happens when your patient has exhausted options for oral preventatives? Trials of BOTOX injections are usually the next alternative.

BOTOX currently costs about $1,200 for a 200 U vial-the smallest vial needed for chronic migraine treatment. This price seems high. Is it worth it?

Rothrock and colleagues¹ looked at healthcare utilization by patients with chronic migraine 6 months before and after they initiated BOTOX injections. The authors determined how often these patients used an urgent care center (UCC) and/or an ED- and/or the number of days hospitalized during those periods.

Use of these facilities fell during the treatment period. Specifically, the number of ED visits dropped from 1.67 to 0.92 per patient; UCC visits decreased from 0.65 to 0.39; and days of hospitalization diminished from 0.20 to 0.11. However, the reduction in costs from diminished use of health care equaled only about 50% of the cost of the BOTOX injections given over the same period.

I’ll admit that at first I was disappointed. I was hoping to find that cost reductions more than paid for the injections. I was thinking, “it’s cheaper to let patients have access to higher healthcare utilization than to inject them with BOTOX once every 3 months.”

But the authors must have known what I was thinking. They noted that the study didn't include hidden costs that BOTOX injections may obviate, and concluded that the estimated cost-offsets are conservative. Among the costs that BOTOX may have saved:

. The expense of extra prescriptions to control breakthrough migraines

. Savings from fewer doctor’s visits

. Savings from laboratory and imaging studies that will not be ordered because the patient is feeling better

. Savings from not having to take time off to go to a UCC or ED or hospital

. Savings for employers when someone can’t do his or his job fully or who makes errors; also the cost of replacing a sick employee

. The price family members pay from lack of companionship or childcare help when a partner has a migraine

If these costs don’t more than equal the other 50% of the cost of BOTOX injections, then someone is not doing his math correctly.